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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_903_Библиотеки_им_академика_М_И_Перельмана.pdf
172
T. J. Swope
is no immediate plan for a liver transplantation. Hernia repair with mesh is associated
with lower recurrence rate, but with higher surgical site infection when compared
to hernia correction with conventional fascial suture [17]. There is no consensus on
the best abdominal wall layer in which the mesh should be placed: Onlay, sublay, or
underlay. Many studies have demonstrated several advantages of the laparoscopic
umbilical herniorrhaphy in cirrhotic patients compared with open surgical treatment.
Conclusion
Umbilical hernia repair can be approached in a variety of MIS approaches includ-
ing IPOM, TAPP, retro-rectus, and component separation. The use of mesh
appears to lower recurrence rates. An MIS approach is favored with increasing
hernia size and patient BMI.
References
1. Earle DB, McLellan JA. Repair of umbilical and epigastric hernias. Surg Clin North Am.
2013;93(5):1057–89.
2. Nguyen MT, Berger RL, Hicks SC, Davilla JA, Kao LS, Jiang MK.Comparison of outcomes
of synthetic mesh vs suture repair of elective primary ventral herniorrhaphy: a systemis review
and meta-analysis. JAMA Surg. 2014;149(5):415–21.
3. Rutkow IM.Epidemiologic, economic, and sociologic aspects of hernia surgery in the United
States in the 1990s. Surg Clin North Am. 1998;78:941–51.
4. Muysoms FE, Miserez M, Berrevoet F, Campanelli G, Champault GG, Chelala E, et al.
Classication of primary and incisional abdominal wall hernias. Hernia. 2009;13:407–14.
5. Schumpelick V.The umbilical hernia. In: Fitzgibbons RJ, editor. Recurrent hernia prevention
and treatment. Berlin: Springer; 2007. p.359–64.
6. Rodriguez JA, Hinder RA.Surgical management of umbilical hernia. Oper Tech Gen Surg.
2004;6(3):156–64.
7. Mulhollan M, et al. Greeneld’s surgery: scientic principles and practice. Philadelphia:
Lippincott Williams & Wilkins; 2011. p.1131.
8. Mayo WJ.An operation for the radical cure of umbilical hernia. Ann Surg. 1901;34:276.
9. Arroyo A, García P, Pérez F, Andreu J, Candela F, Calpena R.Randomized clinical trial com-
paring suture and mesh repair of umbilical hernia in adults. Br J Surg. 2001;88:1321–3.
10. Sanjay P, Reid TD, Davies EL, Arumugam PJ, Woodward A. Retrospective comparison of
mesh and sutured repair for adult umbilical hernias. Hernia. 2005;9:248–51.
11. Lau H, Patil NG.Umbilical hernia in adults. Surg Endosc. 2003;17(12):2016–20.
12. Ponten JE, Thomassen I, Nienhujis SW.A collective review on mesh-based repair of umbilical
and epigastric hernias. Indian J Surg. 2014;76(5):371–7.
13. Colon MJ, Kitamura R, Telem DA, Nguyen S, Divino CM.Laparoscopic umbilical hernia
repair is the preferred approach in obese patients. Am J Surg. 2013;205:231–6.
14. Giurgius M, Bendure L, Davenport DL, Roth JS.The endoscopic component separation tech-
nique for hernia repair results in reduced morbidity compared to the open component separation technique. Hernia. 2012;16(1):47–51.
15. Shell DH, de la Torre J, Andrades P, Vasconez LO.Open repair of ventral incisional hernias.
Surg Clin North Am. 2008;88:61–83.
16. Köhler G, Luketina RR, Emmanuel K.Sutured repair of primary small umbilical and epigas-
tric hernias: concomitant rectus diastasis is a signicant risk factor for recurrence. World J
Surg. 2015;39(1):121–6.
17. Coelho JC, Claus CM, Campos AC, Costa MA, Blum C.Umbilical hernia in patients with liver
cirrhosis: a surgical challenge. World J Gastrointest Surg. 2016;8(7):476–82.
Bridging Versus Closing theDefect
During MIS Ventral Hernia Repair: Pros
13
andCons
MorrisE.Franklin Jr, MiguelA.Hernández,
andPhilipMasonHamby
Introduction
The effective repair of ventral and incisional hernias is a challenging and dynamic
eld that continues to advance with research and innovation. Primary suture repair
of ventral hernias has now largely been abandoned due to high recurrence rates.
Prosthetic mesh placement is now the standard of care for all but the smallest ventral hernias. Mesh placement has been described above, below, and within each
layer of the abdomen. Intraperitoneal onlay mesh (IPOM) technique places a mesh
within the peritoneal cavity and below the peritoneum. Once implanted, the mesh
forms an inammatory reaction with the peritoneum, creating a durable and tensile
prosthesis. Literature has shown IPOM to be an efcacious repair with reduced
complications. Here we discuss the origins of the IPOM as well our experience and
technique using the IPOM repair.
History
Laparoscopic ventral and incisional hernia repair was introduced in 1993 with the
ndings of LeBlanc and Booth who described laparoscopic IPOM [1]. The adhesions were reduced laparoscopically, and a mesh was placed, bridging the defect
with a generous overlap of mesh on the lateral margins. This was a marked improvement from the open technique, because it avoided an extensive soft tissue dissection. In addition to this, the technique had a relatively short learning curve, low
postoperative complication rate, and attractive long-term durability. Many patients
developed seromas in the unclosed hernia sacs. These often resolved but in some
P. M. Hamby · M. A. Hernández (*) · M. E. FranklinJr
Department of Minimally Invasive Surgery, Texas Endosurgery Institute,
San Antonio, TX, USA
e-mail: franklin@texasendosurgery.com
© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2019
S. S. Davis Jr. et al. (eds.), The SAGES Manual of Hernia Surgery,
https://doi.org/10.1007/978-3-319-78411-3_13
173
174
M. E. Franklin et al.
cases remained as chronic cavities or developed infection. Additionally, patients
occasionally develop an anterior bulge mitigating perceived cosmesis [2, 3].
To address these issues, some surgeons advocated reapproximation of the hernia
edges before mesh placement. Seromas would still form in the hernia cavity, but by
approximating the hernia edges, an additional tissue barrier was created between the
mesh and seroma cavity. In addition, the mesh was even further dislocated from the
supercial subdermal layers, theoretically lowering the risk of mesh involvement
with the skin or infection. Another signicant advantage of defect closure was restoration of natural abdominal contour resulting in improved perceived cosmesis
[4–7].
Studies assessing laparoscopic ventral hernia repair show that recurrence rates
usually range from 4.2 to 16.7% [6, 8, 9]. In some literature recurrence rates can be
as low as 0–2.9% [10, 11]. Data also shows that IPOM provides patients with many
of the expected benets of minimally invasive surgery. Hospital length of stay is
shortened, and patients have less postoperative pain.
Research has also specically addressed reapproximation of hernia edges. In
2011, Novitsky etal. published a “shoelacing” technique for ventral hernia repair
and reapproximation of the hernia edges. They described their technique in 47
patients in a period of 32months with no wound-related complications, no seromas,
no infections, and zero recurrences in a mean follow-up of 16.2months [12]. Some
published data are not as optimistic. A recent study found that approximation of
hernia edges before mesh placement did not reduce recurrence, postoperative pain,
or surgical site infection, when compared with a bridging mesh applied in IPOM
technique [11].
At the Texas Endosurgery Institute, we have more than 25years of experience
performing laparoscopic ventral hernia repair, likely representing one of the largest
series worldwide. In 2004 we published a scientic paper including 384 patients.
Ninety-six percent of the procedures were completed laparoscopically. We had 11
(2.9%) recurrences during a mean follow-up of 47.1months [7]. Currently, in our
database and ready to publish, we have 1107 patients. We have reviewed 699 (63%)
laparoscopic ventral and incisional hernia repairs and 408 (37%) laparoscopic
umbilical hernia repairs. The mean follow-up has been 52.3months. We had 23
(2%) recurrence cases, 16 of them in incisional and ventral hernias and 7in umbilical hernias. Eight of these patients had chronic obstructive pulmonary disease
(COPD). We found 17 (1.5%) with seromas, all of them treated conservatively.
Technique
Preoperative Management andPatient Selection
All patients undergo routine preoperative laboratory studies, complete blood count,
blood chemistries, chest radiography, electrocardiogram, and CT scan. Preparation
for surgery includes preoperative antibiotics and formal bowel preparation, if the
bowel is signicantly involved in hernia and the patient is not obstructed.
13 Bridging Versus Closing theDefect During MIS Ventral Hernia Repair
175
Procedure
General anesthesia is used, and nasogastric tube and Foley catheter are placed. The
patient is placed in supine position and rmly attached to the table to allow changes
in position such as Trendelenburg, reverse Trendelenburg, and side-to-side rotation.
We prefer to secure the patient to the table with tape at the shoulder level. Sequential
compression devices are applied to the legs. Video monitors are positioned at the
foot of the table or at a place convenient for viewing by all of the surgical team.
Insufation is obtained with a Veress needle, usually from a non-midline location. The initial 5mm ports are placed lateral to the rectus muscles. The adhesions
opposite the initial ports are carefully taken down, and additional ports are placed as
adhesions are cleared. Each of these additional trocars should be considered as a
port through which a stapler or laparoscope can be placed. Therefore, any port can
be upsized to 10–12-mm trocars when needed. Bleeding must be meticulously controlled and bowel injury avoided as the anterior abdominal wall is being cleared.
The hernia defect is localized, and the adhesions and hernia sac are dissected before
starting to close the defect (Figs.13.1 and 13.2).
We close the defect with strong suture, even if only a partial closure is possible.
In our practice, this is usually accomplished percutaneously, using the CarterThomason (Inlet Medical, Inc., Eden Prairie, MN, USA) suture passer with placement of #1 (PDS) polydioxanone (Ethicon, Somerville, NJ, USA) as individual and
horizontal sutures 1.5–2cm apart (Figs.13.3 and 13.4).
Once the sutures are placed in the edges of the defect, the pneumoperitoneum
pressure is lowered to 6mmHg; this allows for easier closure of the defect with
decreased tension. The corners of the defect are tied rst, while the assistant holds
tension on the middle sutures to approximate the defect. This facilitates large defect
closure without tearing the fascia (Figs.13.5 and 13.6). Almost all defects can be
Fig. 13.1 Hernia defect
176
Fig. 13.2 Dissection of
hernia sac
Fig. 13.3 Suture
placement
M. E. Franklin et al.
closed by this method; however, there are circumstances where the defect is not
closed, such as a rigid abdomen or in loss of abdominal domain. After defect closure, pneumoperitoneum is reestablished to 12mmHg.
A mesh is selected to cover as many defects as possible and to provide a minimum overlap of 3–5cm circumferentially around each side of the defect (Figs.13.7
and 13.8). Although one piece of mesh is ideal, it may not be possible in all instances,
especially those abdomens where extensive, multiple, or widely spaced defects are
present. The mesh is afxed over the defect with staples or tacks and, in some cases,
transfascial circumferential sutures using nonabsorbable suture (2-0 Prolene)
(Figs.13.9, 13.10, 13.11, and 13.12).
All trocar sites greater than 5mm should be carefully and completely closed and
the abdomen desufated after covering the mesh with omentum. The omentum
serves as barrier to separate the mesh from the bowel and to allow adhesions to
13 Bridging Versus Closing theDefect During MIS Ventral Hernia Repair
Fig. 13.4 Using suture
passer
Fig. 13.5 Tying sutures
177
preferentially form with omentum rather than bowel. Operating times vary with
severity of adhesions, number of defects, bowel involvement, and need for concurrent procedures.
Postoperative Management
The postoperative course is relatively straightforward. The nasogastric tube and
Foley catheter are removed in the recovery room in most instances. We fully explain
to patients that seroma formation is common and watch this expectantly without
drainage. The patient is given a diet when bowel sounds are present. Patients are
178
Fig. 13.6 Closed hernia
defect
Fig. 13.7 Mesh in the
abdomen
M. E. Franklin et al.
Fig. 13.8 Pulling the
mesh
13 Bridging Versus Closing theDefect During MIS Ventral Hernia Repair
Fig. 13.9 Mesh xation with
tackers
Fig. 13.10 Mesh xation
with staples
179
180
Fig. 13.11 Transfascial
suture
Fig. 13.12 Transfascial
suture
M. E. Franklin et al.
allowed to go home when they are afebrile, their wounds are clean, a regular diet is
tolerated, and only minimal pain is present.
Patients are routinely seen back in the clinic by the operating surgeon at 2weeks,
1month, 3months, 6months, and yearly thereafter.
Complications
The most common complication encountered is the seroma formation. Many
patients develop a small, sterile uid collection that does not require further treatment and eventually reabsorbs. Another commonly described complication is the
13 Bridging Versus Closing theDefect During MIS Ventral Hernia Repair
181
conversion to an open procedure. Many times this is secondary to poor visualization
from dense adhesions and in some cases from profound bowel dilatation.
Hernia repair is associated with a signicant risk of enterotomy, and complications related to a missed enterotomy can have devastating effects. Multiple adhesions or prior abdominal surgery increases the risk of bowel injury. Other described
complications include trocar site infection, prolonged ileus, urinary tract infection,
pseudo-obstruction, and pulmonary problems. Less commonly, patients can also
have recurrent pain and suture-site neuralgia. Mesh infections are relatively rare and
are usually associated with enterotomy.
Conclusions
Overall, in our experience, we have consistently noted decreased complications
and morbidity with the IPOM repair using reapproximation of hernia edges.
Patients are well satised with repair cosmesis, and from our data, the repair has
an enviably low recurrence rate.
In our experience, reapproximation of hernia edges during IPOM technique
appears to reduce recurrence and provide improved cosmesis. Our data from the
past 25years is one of the largest case series worldwide that clearly supports
closure and reapproximation during IPOM ventral hernia repair.
References
1. LeBlanc KA, Booth WV.Laparoscopic repair of incisional hernias using expanded polytetrauorethylene: preliminary ndings. Surg Laparosc Endosc. 1993;3:39–41.
2. Shoenmaeckers E, Wassenar EB, Raymakers JT, Bakic S.Building of the mesh after laparoscopic repair of ventral and incisional hernia. J Soc Laparoendoc Surg. 2010;14(4):541–6.
3. Tse GH, Stutheld BM, Duckworth AD, de Beaux AC, Tulloh B.Pseudo-recurrence following
laparoscopic ventral and incisional hernia repair. Hernia. 2010;14(6):583–7.
4. Palanivelu C, Jani KV, Senthilnathan P, etal. Laparoscopic sutured closure with mesh reinforcement of incisional hernias. Hernia. 2007;11:223–8.
5. Agarval BB, Agarwal S, Mahajan KC.Laparoscopic ventral hernia repair: innovative anatomical closure, mesh insertion without 10mm transmyofacial port, and atraumatic mesh xation:
preliminary experience of a new technique. Surg Endos. 2008;23(4):900–5.
6. Chelala E, Thoma M, Tatete B, Lemye AC, Dessily M, Alle JL.The suturing concept for laparoscopic mesh xation in ventral and incisional hernia repair: mid-term analysis of 400 cases.
Surg Endosc. 2007;21:391–5.
7. Franklin ME, Gonzalez JJ, Glass JL, Manjarrez A.Laparoscopic ventral and incisional hernia
repair: 11-year experience. Hernia. 2004;8:23–7.
8. Pierce RA, Spitler JA, Frisella MM, etal. Pooled data analysis of laparoscopic versus open
ventral hernia repair: 14 years of patient data accrual. Surg Endosc. 2007;21:378–86.
9. Heniford BT, Park A, Ramshaw BJ, etal. Laparoscopic repair of ventral hernias: nine years’
experience with 850 consecutive hernias. Ann Surg. 2003;238:391–9; discussion 399–400.
10. LeBlanc KA.Incisional hernia repair: laparoscopic techniques. World J Surg. 2005;29:1073–9.
11. Wennergren JE, Askenasy EP, Greenberg JA. Laparoscopic ventral hernia repair with primary fascial closure versus bridged repair: a risk adjusted, comparative study. Surg Endosc.
2016;30:3231–8.
12. Orenstein SB, Dummer JL, Monteagudo J, Poi MJ, Novitsky W.Outcomes of laparoscopic
ventral hernia repair with routine defect closure using “shoelacing” technique. Surg Endosc.
2011;25:1452–7.